Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care. (using the format SOAP note)
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
SCENARIO: Yvette is a 28-year-old female who walked in without an appointment to be seen for vaginal bleeding. She is an established patient who is 16 weeks pregnant, and this is her first pregnancy. She is crying and accompanied by her husband. A medical assistant escorts them to a room. Her blood pressure is 138/88 mmHg, pulse 84, respirations 16, temperature 98.4°F, and her weight is 145 lb. A urine sample has been obtained. A review of her prenatal care record reveals that she had a normal initial exam, normal lab values and screening tests, takes prenatal vitamins and folic acid, size equals dates, fetal heart tones obtained by Doppler at 14 weeks were 167 bpm, and she is Rh negative. A pelvic exam is performed with a small amount of dark red blood seen in the vaginal vault. The cervix appears closed and there is no visible discharge at the cervix or in the vagina. A wet prep and sample for chlamydia and gonorrhea are gathered. The uterus is palpated and the uterine size equals dates, the external cervical os is closed. No fetal heart tones are heard via Doppler. The wet prep demonstrates many red blood cells, small amount of white blood cells, normal squamous epithelial cells, a moderate amount of bacteria, no spores or pseudohyphae, no trichomonads, and the whiff test is negative.
What additional history should be gathered, and what labs should be collected?
Based on your differential diagnoses, what is the next diagnostic modality that should be performed, and what interventions, if any, should be taken?
Provide evidence from the research to support your decision-making.
